Health inspection·April 4, 2024

F 0552 stated they did not wish for Resident 1 to see the dentist. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/2/24 at 3:00 pm, RP 1 indicated the hygienist is said to have seen Resident 1, but RP 1 reported they were never told what, if anything was found. RP 1 stated, Maybe a dentist could have stopped this from being so extreme if [Resident 1] could have seen a dentist prior to now. Residents Affected - Some During a review of RDHAP evaluation following Resident 1's oral evaluations and treatment dated 1/4/22, 5/27/22, 2/24/23, 4/21/23, 6/30/23, 1/16/24, and 3/22/24. The RDHAP evaluation for Resident 1 indicated, several teeth missing, visible cavitation, retained roots, and general demineralization. During a review of Resident 1's Progress Note dated 6/7/23, Progress Note indicated, the nurse phoned RP 1 after Resident 1 stated she lost a tooth. The nurse went to check on Resident 1 and stated Resident 1's left lower tooth fell out, it was a complete tooth. Resident 1 has no complaint of bleeding or pain. Resident 1 and RP 1 does not want Resident 1 to see a dentist. During a review of Resident 1's Multidisciplinary Care Conference Notes (MCCN), dated 1/18/24. The MCCN indicated; it was an annual conference held on 1/18/24. In attendance were: RP 1, Nursing, Dietary Manager, Therapy, Social Services, and Activities. The conference was performed via telephone call. Dental Consult is as a subject listed to be addressed but was not marked as having been addressed or dental issues having been discussed. 2. A review of Resident 2's medical record indicated that resident 2 was admitted on [DATE] with diagnoses that included, Frontotemporal Neurocognitive Disorder (a group of brain diseases that mainly affect the frontal and temporal lobes of the brain. These areas of the brain are associated with personality, behavior, and language), Urinary Tract Infection (UTI), and High blood pressure. During a review of RDHAP evaluation following resident 2's oral evaluation dated 1/4/24, the RDHAP documentation for Resident 2 indicated, several teeth missing, retained roots, general demineralization, and fractured teeth. During a review of Resident 2's MCCN dated 4/9/24, the MCCN indicated it was an annual conference held on 4/9/24. In attendance were Resident 2, RP 2, Nursing, Dietary Manager, Therapy, Social Services, Activities. The conference was performed via telephone call. Dental Consult is a subject listed to be addressed but was not marked as having been addressed or dental issues having been discussed. 3. A review of Resident 3's medical record indicated that resident 3 was admitted on [DATE] with diagnoses that included, Systemic Involvement of Connective Tissue (The body is held together by tissues that connect and make all the structures within. These tissues are negatively affected), Emphysema (A lung condition that causes shortness of breath, the air sacs of the lungs are damaged and do not work effectively), and Epilepsy (Brain condition that causes recurring seizures). During a review of RDHAP evaluation following resident 3's oral evaluation and treatment dated 1/3/24, the RDHAP prepared evaluation for Resident 3 indicated, White Spot Lesions, General Demineralization, and Visible Cavitation. During a review of Resident 3's MCCN dated 3/13/24, the MCCN indicated; it was a quarterly conference held on 3/13/24. In attendance were: Resident 3, RP 3, Nursing, Dietary Manager, Therapy, Social Services, and Activities. The conference was performed via telephone call. Dental Consult is a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056231 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056231 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some subject listed to be addressed but was not marked as having been addressed or dental issues having been discussed. During an interview on 4/5/24 at 8:00 am, with Social Services Director (SSD) in the SSD's office, SSD stated, during Resident 1, 2, and 3's care conferences, there has been nothing to report. The respective RPs (1, 2, and 3) may be told of the date of the last evaluation and cleaning. SSD confirmed it was unknown if anything was mentioned regarding dental services or results of the RDHAP evaluation. SSD stated there were no recommendations from the RDHAP for Resident 1, 2 or 3 to refer them to a dentist, thus RPs 1, 2, or 3 would not have been notified of a dentist consult need. During an interview on 4/5/24 at 9:00 am, RDHAP stated, I do not diagnose, I just put what I see and do for treatment in my documentation .I identify what I see so social services can let families know and they can go over my evaluation notes in care conferences. I expect that they go over my results in the care conference so that family can decide if they should go to the dentist. During an interview on 4/18/24 at 9:30 am, with Admin, Admin confirmed, no communications occurred regarding whether or not obtaining further dental treatment from a Dentist was desired for Residents 1, 2, and 3 via their respective RPs (1, 2, and 3). The RDHAP made no recommendations for referrals to obtain dentist treatment, thus, no further discussion for RP 1, 2, or 3 regarding dentist treatment determinations were pursued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056231 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056231 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately evaluate and record assessments reflective of the resident's dental status for 4 of 5 residents (Residents 1, 2, 3, and 4), when the Minimum Data Set (MDS, a standardized assessment tool used to evaluate problems for care planning and interventions), indicated that: Residents Affected - Some 1. Resident 1 did not have cavities (permanently damaged area of hard part of tooth with decay that become tiny openings),or broken natural teeth. 2. Resident 2 , did not have cavities (permanently damaged area of hard part of tooth with decay that become tiny openings),or broken natural teeth. 3. Resident 3 did not have cavities (permanently damaged area of hard part of tooth with decay that become tiny openings),or broken natural teeth. 4. Resident 4 was coded as endentulous meaning no teeth or dentures when Resident 4 had a full set of dentures. These failures had the potential to result in mismanagement of the resident's dental health status by not identifying dental problems adequately and providing the correct ongoing treatment, the residents would potentially have continued overall dental and health decline, with a negative impact on the resident's psychosocial and emotional well-being. Findings: During a review of the facility's policy and procedure titled, Comprehensive Assessment , Revised 10/2023, Comprehensive Assessment indicated, Comprehensive MDS assessment are conducted .The facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity .process includes direct observation and communication with residents . 1. A review of Resident 1's medical record indicated that Resident 1 was admitted on [DATE] with diagnoses that included, Activated Protein C Resistance (hereditary condition that affects the clotting factors in blood), Degenerative Disease of the Nervous System (Progressive and chronic conditions that damage and destroy parts of your nervous system, especially the brain), and Anemia (Condition where blood does not have adequate amounts of healthy red blood cells to provide enough oxygen to body tissues). During an observation on 4/4/24 at 3:20 pm, with Resident 1 in the resident's room, Resident 1's teeth appeared clean. The front teeth are apparently part of a partial (fully removable denture inserts that replace one or more missing teeth, not full denture). The canine (sharp teeth on either side of the front teeth) on the right is mostly root under the gumline and noted there are many missing teeth and multiple cavities, discolored, dark-gray to blackish. Additionally noted is a retained root in the low left jaw towards the back. During a review of Registered Dental Hygienist of Alternative Practice (RDHAP ) evaluation form following resident 1's oral evaluations and treatment dated 4/14/22, 5/27/22, 2/24/23, 4/21/23, 6/30/23, 11/1/23, 1/18/24, and 3/22/24. The RDHAP evaluation form indicated, several teeth missing, visible (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056231 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056231 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cavitation, retained roots, and general demineralization (outermost layer of tooth starts to weaken and deteriorate). During a review of Resident 1's Weekly Nursing Progress Note dated 3/4/24, 3/11/24, 3/18/24, and 3/25/24, indicated, Section D. Oral Teeth the MDS nurse marked resident has Own Teeth , other options not marked, but applicable are, Missing Teeth, and Partial. During a review of Resident 1's Weekly Nursing Progress Note dated 4/1/24, 4/8/24, and 4/15/24, indicated, Section D. Oral Teeth nursing marked resident has Own Teeth, and Missing Teeth , other option not marked, but applicable is, Partial. During a review of Resident 1's MDS, 3.0 Section L – Oral/ Dental Status dated 1/19/24, (Annual assessment) indicated, No was answered to the question, No obvious or likely cavity or broken natural teeth? 2. A review of Resident 2's medical record indicated that resident 2 was admitted on [DATE] with diagnoses that included, Frontotemporal Neurocognitive Disorder (a group of brain diseases that mainly affect the frontal and temporal lobes of the brain. These areas of the brain are associated with personality, behavior, and language), Urinary Tract Infection (UTI), and High blood pressure. During a review of RDHAP evaluation following Resident 2's oral evaluation and treatment dated 1/4/24. The RDHAP evaluation for Resident 2 indicated, several teeth missing, retained roots, general demineralization, and fractured teeth. During a review of Resident 2's MDS 3.0 Section L – Oral/ Dental Status dated 4/9/24, (Annual assessment) indicated, No, was answered to the question, No obvious or likely cavity or broken natural teeth? . 3. A review of Resident 3's medical record indicated that resident 3 was admitted on [DATE] with diagnoses that included, Systemic Involvement of Connective Tissue (The body is held together by tissues that connect and make all the structures within. These tissues are negatively affected), Emphysema (A lung condition that causes shortness of breath, the air sacs of the lungs are damaged and do not work effectively), and Epilepsy (Brain condition that causes recurring seizures). During a review of RDHAP prepared evaluation following Resident 3's oral evaluation and treatment dated 1/3/24. The RDHAP prepared evaluation for Resident 3 indicated, [NAME] Spot Lesions (damaged tissue, such as a wound), General Demineralization, and Visible Cavitation. During a review of Resident 3's MDS 3.0 Section L – Oral/ Dental Status dated 12/21/23, (Annual assessment) indicated, No was answered to the question, No obvious or likely cavity or broken natural teeth . No, was answered to both questions No abnormal mouth issues (ulcers, masses, oral lesions .)? and No obvious or likely cavity or broken natural teeth? 4. A review of Resident 4's medical record indicated that Resident 4 was admitted on [DATE] with diagnoses that included, Hemiplegia and Hemiparesis following other Cerebrovascular (CVA, stroke) disease affecting right dominant side (weakness and paralysis on one side of the body (right) following a stroke), Aphasia following CVA (Disorder affecting communication; speech and language), and Convulsions (rapid involuntary muscle contractions that cause uncontrollable shaking and limb movement). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056231 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056231 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 4/18/24 at 9:30 am, with Administrator (Admin) via email, face sheet (Resident demographics) of Resident 4 was reviewed, and Resident 4 was noted to be edentulous. Admin confirmed that Resident 4 has top and bottom dentures. During a review of Resident 4's MDS 3.0 Section L – Oral/ Dental Status dated 6/8/23, (Annual assessment) indicated, No, was answered to the question No natural teeth or tooth fragments (edentulous). During an interview on 4/5/24 at 1:10 pm, with MDS nurse in the MDS office, MDS nurse stated, in order to complete an MDS section the resident has to be visibly observed. Nursing notes and other documentation are reviewed, but for dental issues, the resident's mouth must actually be looked into and checked for issues. Then the MDS nurse must complete the MDS by marking the appropriately boxes to answer the questions. According to the MDS nurse, the MDS policy and guidance states that the person doing the MDS should look in the mouth for section L. If any broken teeth, roots left, or cavities are seen, obvious, or likely then you answer Yes, to the question, No obvious or likely cavity or broken natural teeth? If the resident has lesions, ulcers, or masses in the mouth, then you answer Yes, to the question, No abnormal mouth issues (ulcers, masses, oral lesions .)? If the resident doesn't have teeth and has dentures, you answer Yes, to the question, No natural teeth or tooth fragments (edentulous)? During an interview on 4/5/24 at 3:30 pm, with Admin and Director of Nursing (DON), both confirmed that the MDS' for Residents 1, 2, 3, and 4 were incorrectly coded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056231 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056231 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to pursue routine or emergency dental services with a Dentist to inspect, diagnose, obtain diagnostic testing, and provide treatment when 3 of 5 residents sampled for dental care (Residents 1, 2, 3), were evaluated by the Registered Dental Hygienist of Alternative Practice (RDHAP), who identified dental problems and there was no follow up with a Dentist. Residents Affected - Some 1. Resident 1 was identified to have cavities (permanently damaged area of hard part of tooth with decay that become tiny openings) and retained roots and was not referred to a dentist. 2. Resident 2 was identified to have retained roots and fractured teeth and was not referred to a dentist. 3. Resident 3 was identified to have white spot lesions and cavities and was not referred to a dentist. These failures had the potential to result in progressive oral health decline, loss of teeth, oral pain, infection, reduced appetite, loss of weight, with overall health and emotional deterioration. Findings: During a review of the facility's policy and procedure titled, Dental Consultant , Revised 4/2007, Dental Consultant indicated, Dental care shall be provided through the services of a Consultant Dentist .Providing a dental assessment of each resident .Performing or supervising an annual dental reevaluation for each resident .Providing staff in-service education Assuring that emergency dental services are available .Providing necessary information concerning residents to appropriate staff, care conferences, and/or committees. During a review of the facility's policy and procedure titled, Routine Dental Care , Revised 4/2007, Routine Dental Care indicated, Each resident will receive routine dental care. Our facility's routine dental care includes, but is not limited to: Preventative care and treatment. During a review of the facility's policy and procedure titled, Emergency Dental Care , Revised 4/2007, indicated, Emergency dental care is available to all residents of the facility .Emergency dental services include services needed to treat an episode of acute pain in teeth, gums, or palate (roof of the mouth); broken, or otherwise damaged teeth, or any problem of the oral cavity (mouth) appropriately treated by a dentist that requires immediate attention. During a review of the facility's policy and procedure titled, Availability of Services, Dental , Revised 8/2007, Availability of Services, Dental indicated, Oral healthcare and dental services will be provided to each resident .Dental services are available to all residents requiring routine and emergency dental services. During a review of the facility's policy and procedure titled, Dental Examination/ Assessment , Revised 12/2013, Dental Examination/ Assessment indicated, Dental examinations will be made by the resident's personal dentist or by the facility's Consultant Dentist .Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056231 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056231 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled, Dental Services , Revised 3/2017, indicated, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Routine and 24-hour emergency dental services are provided to our residents through: Referral to a personal dentist .Referral to a community dentist .Referral to other health care organization that provides dental services. Residents Affected - Some During a review of Dental Hygiene Scope of Practice Contract . Signed 11/28/16 by RDHAP, the Dental Hygiene Scope of Practice Contract indicated, RDHAP agrees to provide dental hygiene services for the residents of the facility .will examine each resident's oral condition and .assist in the acquisition of appropriate dental care in the community. 1. A review of Resident 1's medical record indicated that resident 1 was admitted on [DATE] with diagnoses that included, Activated Protein C Resistance (hereditary condition that affects the clotting factors in blood), Degenerative Disease of the Nervous System (Progressive and chronic conditions that damage and destroy parts of your nervous system, especially the brain), and Anemia (Condition where blood does not have adequate amounts of healthy red blood cells to provide enough oxygen to body tissues). During an interview on 4/2/24 at 3:00 pm, with Resident 1's Resident Representative (RP), RP 1 stated, Resident 1 has not been seen by a dentist for the 2 years while living at the facility. Resident 1 complained of tooth pain. RP 1 was communicated with about the tooth pain, and was agreeable for Resident 1 to be sent to Dentist 1. Dentist 1 identified all the dental issues initially, but could provide treatment for Resident 1. An appointment was made with Dentist 2. There was an estimate for $26,000, which included 16 caps (covering for an existing tooth to protect from further decay) and an extraction (removal). Resident 1 only has 16 teeth. RP 1 feels this is a delay of care, that if Resident 1 would have seen a dentist previously this issue would not be so extreme. During an Interview on 4/4/24 at 11:30 am, with Administrator (Admin), Admin stated, Resident 1 notified nursing when one of the left lower back teeth broke, and both Resident 1 and RP 1 stated they did not wish for Resident 1 to see a dentist. Resident 1 has been seen by the RDHAP several times and no problems identified. There were no recommendations from the RDHAP following evaluation of Resident 1 indicating Resident 1needed to see a dentist previously . The recent tooth pain reported by Resident 1 dictated we ask RP 1 if Resident 1 could see a dentist for this issue. RP 1 was communicated with and agreed to have Resident 1 seen by Dentist 1. During a concurrent observation and interview on 4/4/24 at 3:20 pm, with Resident 1 in Resident 1's room, teeth are noted to appear clean. The front teeth are apparently part of a partial (replaceable denture fitted to replace one or more teeth, not complete dentures). The canine (sharp teeth on either side of the front teeth) on the right is noted as root under the gumline. There are many missing teeth and what appears to be cavities, discolored, dark-gray to blackish. Additionally noted is at least one more area where there appears to be a retained root in the low jaw towards the back. Resident 1 stated, I don't recall if I had seen a dentist other than just recently, but there is a person that looks at my teeth sometimes. I recently went to the dentist, and they want to do a bunch of stuff to my teeth .The dentist said I had a cavity in every tooth I have .I do have some sensitivity in a couple of my teeth, but usually I have no pain at all .I am willing to do whatever they say I need to have done. My teeth may have some problems, but I think that is probably normal for people my age. During a concurrent interview and record review on 4/5/24 at 8:00 am, with Social Services Director (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056231 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056231 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (SSD) in the SSD office, Resident 1's Multidisciplinary Care Conference Notes (MCCN), dated 1/18/24 were reviewed. The MCCN indicated it was an annual conference held on 1/18/24. In attendance were; RP 1, Nursing, Dietary Manager, Therapy, Social Services, and Activities. The conference was performed via telephone call. Dental Consult is a subject listed to be addressed, but was not marked as having been addressed or any indication that dental issues were discussed. SSD stated, during Resident 1's care conferences there has been nothing to report regarding dental services. RP 1 may have been told of the date of the last evaluation and cleaning. SSD confirmed it was unknown if anything was mentioned regarding dental services or results of the RDHAP evaluation. There were no recommendations from the RDHAP for Resident 1 to refer them to a dentist, thus RP 1 would not have been notified of a dentist consult need. During a concurrent interview and record review on 4/5/24 at 9:00 am with RDHAP on the telephone, the RDHAP's evaluations following resident 1's oral evaluations, dated 4/14/22, 5/27/22, 2/24/23, 4/21/23, 6/30/23, 11/1/23, 1/16/24 and 3/22/24, were reviewed. The RDHAP prepared evaluations for Resident 1 indicated, several teeth missing, visible cavitation, retained roots (top part of tooth missing), general demineralization (outermost layer of tooth starts to weaken and deteriorate), xerostomia (unusually dry mouth, usually due to medication), and light bleeding. No oral pain noted. There are recommendations for the next care to be provided in 3 months. No further recommendations. Comments included: Oral Hygiene (OH, cleanliness of teeth and mouth) is great. RDHAP stated, I do not diagnose, I just put what I see and do for treatment in my documentation. If they complain of pain or something is bothering them in relation to their teeth or gums, like an abscess, or I notice an abscess, I proceed with a recommendation for a referral to a dentist or clinic. If a resident breaks a tooth but the root remains, I will not recommend a dentist referral unless the resident complains of pain. There is a high percentage of residents that have root tips left due to cavities probably. Most of the time it does not bother them. The nerve kind of dies or calcifies (hardens) and doesn't cause pain .I identify what I see so Social Services can let families know and they can go over my evaluation notes in care conferences (MCCN). I expect that they go over my results in the care conference so that family can decide if they should go to the dentist .Resident 1 does have several cavitations and at least one retained root. I have noted those in my documentation over many of these evaluations. On 3/23/24 I noted some new cavities I hadn't felt before, but some of the cavities noted on previous dates I had put the Silver Diamine Fluoride (a topical medication used to treat and prevent cavities and relieve hypersensitivity) on, which hardens the cavity area to give the teeth more life. In the past I believe the family refused to go to the dentist when issues arose. I don't recall Resident 1 losing a tooth. Number (#)20 (teeth are given numbers to identify in one's mouth) did break at the gumline probably due to a cavity . I did not refer to a dentist, that is up to the family to decide. During a review of Progress Notes dated 6/7/23, Progress Notes indicated the nurse phoned RP 1 after Resident 1 stated she lost a tooth. The nurse went to check on Resident 1 and stated Resident 1's left lower tooth fell out, it was a complete tooth. Resident 1 has no complaint of bleeding or pain. Resident 1 and RP 1 do not want Resident 1 to see a dentist. During a review of Resident 1's Doctor's Appointment Form dated 3/25/24, Doctor Appointment Form indicated, Dentist 2 diagnosed root caries (cavities) throughout, recommended treatment are crowns (a type of dental restoration that completely caps or encircles a tooth, needed when a large cavity threatens the health of the tooth) with buildups with the exception of #20 (tooth, left side back lower jaw) that will need extraction (removal). Severe dry mouth observed .Plans: contact patient's caregiver to discuss treatment plan and proceed with treatment plan; Recommend starting with #20 root extraction and upper right quadrant high priority. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056231 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056231 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. A review of Resident 2's medical record indicated that resident 2 was admitted on [DATE] with diagnoses that included, Frontotemporal Neurocognitive Disorder (a group of brain diseases that mainly affect the frontal and temporal lobes of the brain. These areas of the brain are associated with personality, behavior, and language), Urinary Tract Infection (UTI), and High blood pressure. During a concurrent interview and record review on 4/5/24 at 9:00 am, with RDHAP on the telephone, RDHAP's prepared evaluation following resident 2's oral evaluation dated 1/4/24 was reviewed. The RDHAP prepared evaluation for Resident 2 indicated, several teeth missing, retained roots, general demineralization, fractured teeth, and moderate bleeding. No oral pain noted. There are recommendations for the next care to be provided in 3 months. No further recommendations. RDHAP stated, I do not diagnose, I just put what I see and do for treatment in my documentation .I don't recommend the dentist unless they complain of pain. During a review of Resident 2's MCCN dated 4/9/24, the MCCN indicated; it was an annual conference held on 4/9/24. In attendance were: Resident 2, RP 2, Nursing, Dietary Manager, Therapy, Social Services, and Activities. The conference was performed via telephone call. Dental Consult is a subject listed to be addressed but was not marked as having been addressed or dental issues having been discussed. 3. A review of Resident 3's medical record indicated that resident 3 was admitted on [DATE] with diagnoses that included, Systemic Involvement of Connective Tissue (The body is held together by tissues that connect and make all the structures within. These tissues are negatively affected), Emphysema (A lung condition that causes shortness of breath, the air sacs of the lungs are damaged, and do not work effectively), and Epilepsy (Brain condition that causes recurring seizures). During a concurrent interview and record review on 4/5/24 at 9:00 am with RDHAP on the telephone, RDHAP's prepared documentation following resident 3's oral evaluation dated 1/3/24 was reviewed. The RDHAP documentation for Resident 3's oral evaluations indicated, [NAME] Spot Lesions, General Demineralization, Visible Cavitation rampant, and Xerostomia. No oral pain noted. There are recommendations for the next care to be provided in 3 months. No further recommendations. RDHAP stated, I do not diagnose, I just put what I see and do for treatment in my documentation .I don't recommend the dentist unless they complain of pain. During a review of Resident 3's MCCN dated 3/13/24, the MCCN indicated it was a quarterly conference held on 3/13/24. In attendance were Resident 3, RP 3, Nursing, Dietary Manager, Therapy, Social Services, and Activities. The conference was performed via telephone call. Dental Consult is a subject listed to be addressed but was not marked as having been addressed or dental issues having been discussed. During an interview on 4/4/24 at 1:15 pm, with SSD in the SSD office. SSD stated, with regards to Resident 1, 2, and 3, as well as all of the residents, there is not a dentist that comes to the building, there is a hygienist, licensed as a RDHAP that sees all the residents. The RDHAP prepared evaluation form basically tells what was done during the RDHAP visit with the resident. The RDHAP would write recommendations for a dentist referral on the prepared evaluation form if there was a problem. When the RDHAP makes recommendations, by documenting it on the prepared evaluation form, for a resident to see a dentist for dental issues identified, the resident or the resident's respective RP would be notified. The resident or the respective RP would determine if further dentist treatment is desired. If the resident or respective RP agreed to further dentist treatment an appointment would be made by the SSD. The SSD staff does not interpret or read into the RDHAP prepared evaluation form, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056231 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056231 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete further treatment is pursued only if there are recommendations from the RDHAP to pursue further dentist treatment, or if the resident has dental pain, or loses a tooth. During an interview on 4/18/24 at 9:30 am, with Admin and Director of Nursing (DON), Admin and DON indicated that if the RDHAP thought Residents 1, 2, and 3 needed further follow up with a dentist that it would be indicated on the RDHAP prepared evaluation form at the bottom, where it says Recommendations. Admin and DON confirmed that no communications regarding further dental care or treatment were discussed with respective RP's for Residents 1, 2, and 3, because there were no recommendations from the RDHAP. Event ID: Facility ID: 056231 If continuation sheet Page 11 of 11